Multilevel assessment of atherosclerotic extent using a 40-section multidetector scanner after transient ischemic attack or ischemic stroke

One-stop combined coronary-craniocervical computed tomography angiography with low-dose body coverage using artificial intelligence iterative reconstruction: a clinically feasible solution to multi-territorial atherosclerosis diagnosis

Background

Computed tomography angiography (CTA) is an effective means to detect atherosclerosis yet a whole-body scan may involve excessive dose that can only be considered in extreme cases. This study is to test the feasibility and value of adding a low-dose body CTA to the combined coronary-craniocervical CTA by using artificial intelligence iterative reconstruction (AIIR).

Methods

A total of 100 patients scheduled for one-stop combined coronary-craniocervical CTA were enrolled to receive an extended CTA covering from intracranial to iliofemoral arteries, by adding a low-dose body CTA to the coronary-craniocervical CTA. Radiation dose, contrast medium volume and the resulting image quality of the added scan, reconstructed by the AIIR, were compared to those from the retrospectively collected routine-dose aortic CTA. Diagnostic findings beyond the coronary and craniocervical arteries, which would have been missed if not for the extension, and their influence on clinical management, were assessed on the low-dose images.

Results

With rather low cost of radiation and contrast dosage (1.6 mSv, 25.4 mL), the body CTA with AIIR reconstruction yielded diagnostically sufficient image quality and significantly higher contrast-to-noise ratio (CNR) as compared to routine-dose aortic CTA at various vascular locations (all P<0.05). Additional atherosclerosis was detected by the added low-dose body CTA for a substantial proportion of patients (73/100, 73%). Incidental findings in the body were found in 26 patients with 44 detections. The corresponding clinical management of 38% patients was changed due to the atherosclerotic and non-atherosclerotic vascular findings on body arteries. Most of the atherosclerosis were calcified plaques (38/73, 52%) and rated as mild stenosis (62/73, 85%). The prevalence of body arterial atherosclerosis was remarkably higher among patients diagnosed with coronary-craniocervical atherosclerosis than those without coronary-craniocervical atherosclerosis (85% vs. 22%).

Conclusions

Extending the one-stop combined coronary-craniocervical CTA with low-dose body coverage as enabled by the AIIR is technically feasible and of evident clinical value in clinical decision-making, taking a concrete step towards multi-territorial atherosclerosis diagnosis and management in practical application.

Asymptomatic coronary artery disease in ischaemic stroke survivors: A systematic review and meta-analysis

BACKGROUND

Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors.

PATIENTS AND METHODS

We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses.

RESULTS

We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (I2 = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (I2 = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity I2 = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, p = 0.007) for future MACE.

DISCUSSION AND CONCLUSIONS

Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.

ACR Appropriateness Criteria® Cerebrovascular Diseases-Stroke and Stroke-Related Conditions

Cerebrovascular disease encompasses a vast array of conditions. The imaging recommendations for stroke-related conditions involving noninflammatory steno-occlusive arterial and venous cerebrovascular disease including carotid stenosis, carotid dissection, intracranial large vessel occlusion, and cerebral venous sinus thrombosis are encompassed by this document. Additional imaging recommendations regarding complications of these conditions including intraparenchymal hemorrhage and completed ischemic strokes are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it!

Stroke is a major cause of morbidity and mortality worldwide, and effective treatment requires rapid diagnosis and recognition of relevant vascular lesions. In this review we will discuss the usefulness and versatility of computed tomography angiography in the setting of stroke, be it ischemic or hemorrhagic, minor or disabling. Furthermore, we also highlight how we use computed tomography angiography in decision making in transient ischemic attacks, acute disabling ischemic stroke, and hemorrhagic stroke.